Problem: Patient safety issues have been studied widely in the acute care hospital setting;and to a lesser extent in outpatient primary care practices. There are no published studies that describe patient safety incidents that occur during the unique care processes of home hospice care. Purpose: This study explores the types, characteristics, and outcomes of patient safety incidents that occur during the course of home hospice care, and identifies potential opportunities for prevention of harm from such incidents. Research question: This study will complete four specific aims directly related to the following interlinked questions: 1) What are the types, characteristics, and contributing factors of patient safety incidents described by home hospice team members?, 2) What outcomes and potential harms to patients and/or personal caregivers result from patient safety incidents during home hospice care? 3) What early detection or mitigation factors could prevent patient safety incidents or limit their potential for harm in home hospice care? , and 4) Do any patient safety incidents in home hospice care have characteristics of "never events" (readily identifiable, preventable, severe potential for harm), similar to serious patient safety incidents described in hospitals and other care settings? Methods: Individual semi-structured telephone interviews with 100 home hospice team members from 30 hospices chosen at random from a national hospice research network. At least three interviews with different health care professionals will be completed from each home hospice team (primary care nurse, social worker, chaplain, home health aide, physician). Qualitative analysis of individual interviews will consist of computer-assisted content analysis using a codebook developed from the patient safety incident conceptual model (International Classifications for Patient Safety) and the interview guides, with expansion of the codebook from the interviews themselves. During the analysis, common themes and characteristics of patient safety incidents will be summarized and described. A subset of incidents will be identified that have characteristics of "never events" described in other health care settings. Benefits: This will be the first study to explore and describe the types and characteristics of patient safety incidents and adverse outcomes in home hospice care. The study will contribute to development of patient safety guidelines that can be implemented and investigated in future studies.